Patients suffer over gap between physical and mental health care

Family doctors are the first point of contact for most people seeking diagnosis and care, but a disconnect between physicians and mental health professionals leaves many stranded.

When Esme Hurst’s teenage son Alex started showing signs of depression and anxiety, she took him to their family doctor.

His physician diagnosed depression, prescribed an anti-depressant and referred Alex to a local hospital’s youth mental health services.

None of it helped Alex. He got an assessment from hospital staff, but they did not refer him to ongoing treatment. And he hated the anti-depressants, said they made him feel strange.

Family doctors are the first point of contact for thousands of people seeking diagnosis and care for mental illness, but a disconnect between physicians and mental health professionals leaves many patients stranded without an effective path to treatment.

Alex’s depression got worse.

“It just added up and added up on him,” Esme says. “He felt worthless.”

The Hursts returned to their family doctor looking for more options, but he seemed to have exhausted all of his mental health-care resources.

“When I went back to him and said, ‘Can you give us a list of psychologists or psychiatrists or therapists that we could reach out to?’ the doctor said, ‘I don’t know anybody,’ ” Esme recalls.

In the end, the doctor recommended that Esme buy a book on cognitive behaviour therapy and administer the treatment to Alex herself.

They tried it. Esme says she never felt like she knew what she was doing, and Alex had his own doubts about her acting as a therapist.

The Hursts eventually scheduled another assessment at the same hospital, the one their family doctor had referred them to in the first place.

Just days before the appointment, in May 2006, Alex took his own life. He was 15.

More than four million Canadians struggle with anxiety or mood disorders including depression, obsessive compulsive disorder, bipolar disorder and post-traumatic stress disorder. That is more than 11 per cent of this country’s population and more Canadians than have liver, kidney or heart diseases.

But there is a chasm between mental health care and physical health care, and Canadians with mental illness are falling through it.

“The system of mental health care has been poorly co-ordinated,” says Dr. Catherine Zahn, president and CEO of the Centre for Addiction and Mental Health. “There are many primary care physicians (who) actually don’t really know who to call, or aren’t well versed in what services are available in the community or what the right services are for their particular patient.”

Dr. Karen Cohen, CEO of the Canadian Psychological Association, calls family doctors the “gateway to care.”

“That’s where people can easily go, that’s where people feel comfortable. It makes sense,” Cohen says.

The Ontario Medical Association reports that family physicians deliver about half of all mental health services in the province.

But they do not necessarily have the information or expertise necessary to handle mental health cases.

Zahn, a trained neurologist, says patients can often get effective treatment from a family doctor. But, she adds, when that primary care isn’t enough, there has to be a next level.

“(Doctors) will have a small stable of people that they like and know and trust and they will call them, but they won’t necessarily have the information to navigate patients to the range of services that might be available,” Zahn says.

Finding an appropriate path to treatment is especially important for teenage patients like Alex Hurst.

Experts say the majority of mental illnesses surface in childhood or adolescence. For many young people, those illnesses can be fatal.

Suicide accounted in 2012 for 12 per cent of all deaths among 10 to 14-year-olds and 28 per cent of deaths among 15 to 19-year olds.

“It’s one thing to have someone who is older, more mature, has impulse control,” Zahn says. “But a young person who’s depressed, that’s kind of an emergency. It needs to be taken seriously and followed closely.”

Dr. Virginia Walley, president of the Ontario Medical Association, says the lack of integrated programs for patients of all ages has created “silos” of care, in which family doctors and mental health professionals are isolated from each other.

Though each individual care provider may be trying their best to help the patient, the lack of co-operation between them often leads to patients getting inadequate care, Walley says.

“We know Ontario’s doctors and mental health providers will continue to do all they can to meet the needs of their patients,” Walley adds. “However, their ability to achieve results will continue to be impacted by this lack of integration and underfunding of community supports.”

Cohen, at the Canadian Psychological Association, says the solution is probably a combination of increasing mental health literacy among family doctors and placing more psychologists near the front lines of health care.

“Psychologists can be attached to family health-care teams and primary care practices,” Cohen said. “It doesn’t mean they’re the ones seeing every patient for whom there’s a suspicion there might be a mental health problem. But (the psychologist) could be a resource to the family doctor, who could say, ‘You know, I’m not quite sure I have a handle on this. Would you see this person?’ ”

Dr. Jonathan Bertram, a family physician who specializes in mental health and addictions, works part time at CAMH and part time at his Bowmanville practice, in a building with 20 other family doctors’ offices.

“(A patient) knows they can go down the hall and get their issue addressed, or my colleague can message me and talk about it,” Bertram says.

Family doctors without that physical proximity to mental health resources can also apply to a mental health care mentorship program run by the Ontario College of Family Physicians.

The Collaborative Mental Health Network matches family doctors to psychiatrists and psychotherapists for professional development and “case-by-case support.”

“Networks like these are really nice ways of trying to fill in where the gaps are instead of trying to change things completely,” Bertram says.

Patients can still see their trusted family physician, but that trip to the doctor will be a more meaningful first step, he adds.

For Zahn, the provision of adequate treatment for people with mental illness goes back to the “first principles” of care.

“People with mental illness are human beings, they have human rights, they have civil rights and they have health care rights,” she says.

“Until recently, until we demanded it, there’s been very little scrutiny in the quality of care,” she adds.

“You might think it’s just about (spending). It’s not. It’s about being publicly accountable about how to use public dollars, how you create services and ensure that they’re effective.”

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